Exactly how big of a problem is prescription drug abuse, specifically opioids, in the United States? The answer may surprise you. Deaths from opioid analgesics are significantly greater in number than those from cocaine and heroin combined, according to the Centers for Disease Control and Prevention (CDC) report, “Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008.” And the sales of opioid analgesics to hospitals, pharmacies, and practitioners quadrupled between 1999 and 2010, according to the CDC report.

“Most significantly, in less than 10 years we’ve seen a greater than threefold increase in the number of overdose deaths due to opioid analgesics,” said Dr. Stephen Cantrill, chair of ACEP’s Opioid Guideline Writing Panel. “Many of us on the panel were somewhat surprised when we actually reviewed the data that the problem has reached this magnitude.”

The problem is profound enough, said Dr. David Seaberg, ACEP President, for ACEP to develop its “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department,” approved in June. “Both individual states and Congress are starting to look at what we can do to stem the tide of prescription drug abuse,” said Dr. Seaberg. “The problem is that whenever you try to develop one public policy, it just doesn’t fit well in all situations. So ACEP developed our policy as a means to provide guidance, not only for our clinicians, but also for states and the government to at least see that we do have a fair and balanced policy on this.”

And while emergency physicians are in the business of treating acute and even chronic pain, they walk a fine line. “I think the concern our members have is that we want to be able to treat legitimate pain,” said Dr. Seaberg. Some state policies may in fact go too far in trying to control drug-seeking behavior.

“In some states, you have to check a database every time you write an opioid prescription, but when you’re seeing 200 patients a day, should you have to check on every single patient?” said Dr. Seaberg. “That takes time away from my ability to care for patients. And if you’ve got a bone hanging out of your leg, I don’t need to check a database to see if you received a narcotic prescription last month.” Checking such databases, added Dr. Seaberg, should be optional and left to the emergency physician’s discretion, or specific and reasonable guidelines should exist. An example of this would be Tennessee’s law, which provides exceptions to checking the database if less than 7 days of narcotics are written or if the patient has a hospital-based procedure performed, Dr. Seaberg said.

A Call for Research

ACEP’s Opioid Guideline Writing Panel found an immediate lack of data that made devising a clinical policy challenging. “One of the surprising issues that quickly made itself known is the paucity of good studies and data in terms of the critical questions we pose in the policy,” said Dr. Cantrill. “We include a call for future research in the policy with the hope that by getting better data we will be able to have recommendations of a higher level.”

Hitting the Highlights: ACEP’s Opioid Clinical Policy

Below are four critical questions and the recommendations for each that are included in ACEP’s Opioid Clinical Policy.

There are three recommendation levels:

• Level A recommendations – Gen­erally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).
• Level B recommendations – Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).
• Level C recommendations – Other strategies for patient management that are based on Class III studies, or in the absence of any adequate published literature, based on panel consensus.

Critical Questions

1. In the adult ED patient with noncancer pain for whom opioid prescriptions are considered, what is the utility of state prescription drug monitoring programs in identifying patients who are at high risk for opioid abuse?

Recommendations:

Level A recommendations: None specified.

Level B recommendations: None specified.

Level C recommendations: The use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.

2. In the adult ED patient with acute low back pain, are prescriptions for opioids more effective during the acute phase than other medications?

Recommendations:

Level A recommendations: None specified.

Level B recommendations: None specified.

Level C recommendations: (1) For the patient being discharged from the ED with acute low back pain, the emergency physician should ascertain whether nonopioid analgesics and nonpharmacologic therapies will be adequate for initial pain management. (2) Given a lack of demonstrated evidence of superior efficacy of either opioid or nonopioid analgesics and the individual and community risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed. (3) If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (e.g., <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion.

3. In the adult ED patient for whom opioid prescription is considered appropriate for treatment of new-onset acute pain, are short-acting schedule II opioids more effective than short-acting schedule III opioids?

Recommendations:

Level A recommendations: None specified.

Level B recommendations: For the short-term relief of acute musculoskeletal pain, emergency physicians may prescribe short-acting opioids such as oxycodone or hydrocodone products while considering the benefits and risks for the individual patient.

Level C recommendations: Research evidence to support superior pain relief for short-acting schedule II over schedule III opioids is inadequate.

4. In the adult ED patient with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing opioids on discharge from the ED outweigh the potential harms?

Recommendations:

Level A recommendations: None specified.

Level B recommendations: None specified.

Level C recommendations: (1) Physicians should avoid the routine prescribing of outpatient opioids for a patient with an acute exacerbation of chronic noncancer pain seen in the ED. (2) If opioids are prescribed on discharge, the prescription should be for the lowest practical dose for a limited duration (e.g., <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion. (3) The clinician should, if practicable, honor existing patient-physician pain contracts/treatment agreements and consider past prescription patterns from information sources such as prescription drug monitoring programs.

To view ACEP’s entire Opioid Clinical Policy, go to www.acep.org/clinicalpolicies.